Children’s Respiratory Disorders

1. Children’s Respiratory Disorders Epiglottis - RSV/Bronchitis - Pneumonia - Asthma - Cystic Fibrosis Marydelle Polk, Ph.D., ARNP-CS Florida Gulf Coast University

2. Objectives • Describe factors that influence the etiology and course of respiratory infections in children. • Differentiate among Epiglottis, RSV/Bronchitis, Pneumonia, Asthma, and Cystic Fibrosis in terms of etiology, defining characteristics, and nursing management.

3. Respiratory System The respiratory system permits ventilation through the process of inspiration and expiration

4. Respiratory Infections • Influencing factors* Age* Anatomical Size* Resistance* Seasonal Variations • Etiology* H. influenza, Group A -Hemolytic Streptococcus, Staphylococci, Chlamydia trachomatis, Mycoplasma, pneumoccoci

5. Epiglotitis • Definition A severe bacterial infection which causes inflammation of the epiglottis and surrounding areas. • Incidence Usually occurs between the ages of 2 – 5 years of age, but can occur from 7 mos. – 11 years – rarely to adulthood.

6. Epiglottitis • History Abrupt onset – History of pharyngitis. Clinical Signs & Symptoms Wakes up looking very ill, fever, sore throat, dysphagia, drooling, dyspnea, “dog position.”

7. Epiglotitis • Clinical Signs & Symptoms * Anxious/apprehensive * Muffled, froglike croaking * Quiet inspiratory stridor • Always observe for the absence of cough, drooling and agitation – hallmarks of epiglottis.

8. REMEMBER !!! • Never examine the pharynx. • Leave the child in a sitting position – preferably in parent’s lap. • Child is anxious – Do not cause further distress and never leave the child alone. • Cyanosis is a late sign of hypoxia (PO2 < 50).

9. Nursing Diagnoses • Ineffective breathing pattern r/t inflammatory process. • Fear/anxiety r/t difficult breathing and unfamiliar place/procedures.

10. Nursing Coventions • Observe for progressive worsening ofrespiratory status. • Prepare for tracheostomy. • Be prepared for administration of O2,IV antibiotics, sedation. • Monitor VS, LOC, O2 levels, fluid status. • Provide calm reassuring support to child and parents. • Prevention is via the H. influenza B vaccine.

11. Nursing Coventions • Administer antipyretic medication, tepid sponge baths, or cooling mattress if indicated. • If needed, provide cool mist for humidifying air. • Ensure adequate rest and provide a less stressful environment. • Organize nursing care to give adequate rest periods.

12. Early Epiglottitis Note the tripod (dog-like) position and the leaning forward

13. Progressive Epiglottitis

14. Bronchiolitis • Definition – An acute viral infection primarily occurring at the level of the bronchioles. • Etiology – Respiratory Syncytial Virus (RSV).Subgroup A > B in children developing bronchiolitis and pneumonia.

15. Incidence and Transmission * URI of the infant – 2-5 mos. Rare in children over 2 years. Considered to be the most important pathogen in the infant. Usually preceded by a viral URII (RSV).* Increased incidence due to (1) direct contact – hands, eyes, nose, mucous membranes and (2) the virus has a long life span.

16. Clinical Manifestations • Mild (Initial phase) * Rhinorrhea * Pharyngitis * Coughing and sneezing * May present with ear or eye infection * History of intermittent fever

17. Clinical Manifestations • Moderate (Progressive)*  coughing and wheezing* Air hunger and  WOB* Tachypnea and retraction* Cyanosis

18. Sternal Retractions When an infant/child is retracting like this – what else would you observe?

19. Clinical Manifestations • Severe* Tachypnea > 70 breaths/minute* Listlessness* Apnea spells* Poor air exchange*  breath sounds

20. Nursing Diagnoses • Ineffective breathing r/t poor gas exchange. • Altered activity level r/t work of breathing. • Potential of fluid volume deficit r/t poorfluid intake.

21. Nursing Coventions • Provide  humidity – cool, moist oxygen • Adequate fluid intake • Ongoing assessment and monitoring of O2 status, VS, activity level • Possible administration of antiviral agents (RespiGam – used more for prophylactic value)

22. Nursing Coventions • Conserve child’s energy • Observe for signs of dehydration: * Sunken fontanel * Poor skin turgor * Dry mucous membranes * Decreased and concentrated urinary output

23. Remember… As this infection is due to a virus – standard Rx may not prove to be effective in non-complicated situations, including: * antibiotics * bronchodilators * corticosteroids * cough suppressants

24. Pneumonia Inflammation of the alveoli caused by bacteria, virus, Mycoplasma organisms, aspiration, or inhalation.

25. Types of Pneumonia • Lobar – Large areas (segments) of one or both lungs are involved. • Broncho – bronchioles become clogged with thick mucopurulent mucus  consolidates into patches in nearby lobes.

26. Types of Pneumonia – con’t. • Interstitial – Primarily occurs within the alveolar walls and interlobular tissues.

27. Incidence and Etiology Incidence10-20 % of the cases of pneumonia are bacterial;10 % are mixed – both viral and bacterial.70 – 80 % are viral.EtiologyMycoplasma pneumoniae – most common inchildren 5 – 12 years-of-age.

28. Chest x-rays - Pneumonia

29. Clinical Manifestations •  fever • Cough (productive or nonproductive) • Tachypnea • Fine crackles and rhonchi • Chest pain • Retractions and nasal flaring • Pallor to cyanosis • Irritability – restless – lethargic • GI disturbances (nausea, diarrhea, pain, anorexia).

30. Nursing Diagnoses • Ineffective airway clearance r/t inflammation. • Pain r/t inflammatory process: pneumonia

31. Nursing Coventions • Administer and monitor antibiotic therapy (bacterial). • Monitor fluid intake, VS (especially thetemperature – give antipyretics in needed (fever/irritability), bed rest, cool mist humidifier. • In-hospital – monitor O2 if child develops respiratory distress. • Avoid cough suppressants. • Teach parents s/s of respiratory distress and dehydration. • Conserve child’s energy.

32. Reactive Airway Disease - Asthma • Definition – inflammatory process of the large airways, which results in heightened airway reactivity. • An obstructive disorder – due to the inflammation and edema of the mucous membranes,  in thick, tenacious secretions, spasms of the bronchial smooth muscle  a  diameter of bronchioles.

33. Types of Asthma • Mild Intermittent Asthma* S/S  2 times per week* Exacerbations are brief* Nighttime s/s  2 times per month* Asymptomatic between episodes* Does not require chronic drug therapy* Teach and encourage parents to  exposure to allergens

34. Types of Asthma • Mild Persistent AsthmaS/S > 2 times per week - < 1/dayExacerbations may/may not affect exerciseNighttime s/s > 2 times per monthTx with a nonsteroidal Rx - Cromolyn Sodium, a low dose inhaled cortico- steroid or a leukotriene inhibitor.

35. Types of Asthma Moderate Persistent Asthma *Daily s/s*Daily use of short-acting 2-agonist or a low dose long-acting bronchodilator *Exacerbations affect exercise*Exacerbations  2 times per week and may last for days*Nighttime s/s > 1 time per week*May see Nedocromil (Tilade) given in children 5 years or younger in place of long-acting bronchodilator

36. Types of Asthma • Severe Persistent Asthma* Continual s/s* Frequent exacerbations* frequent nighttime s/s* PEFR and/or FEV1 > 1 second and  60 % of predicted value * Tx - high dose inhaled corticosteroids (Vanceril, Flovent) plus oral steroids as needed to control s/s

37. Asthma • Educate child and family about the disease - assist them to identify the triggers - help them in developing an “asthma action” plan AND teach and encourage child to use a peak flow meter regularly as part of his/her action plan to determine management of their s/s.

38. Asthma • Guidelines for child: 80% of child’s baseline is acceptable.50 - 80% of child’s baseline indicates obstruction. 50% of child’s baseline indicates an acute attack.

39. Nursing Diagnoses • Ineffective airway clearance r/t allergenic response and inflammatoryprocess in bronchial airways. • Risk for suffocation r/t bronchospasm,edema and  tenacious mucus.

40. Nursing Coventions • Allergy control • Drug therapy • Chest PT • Hydration • Exercise • Keeping up with immunizations/flu vaccine • Desensitization therapy

41. O2 Delivery Devices

42. Metered Dose Inhaler-Spacer

43. Remember • Assessment - Teaching - Monitoring are hallmarks of effective care for the asthmatic child - whether in an acute care facility or community health center.

44. Cystic Fibrosis • DefinitionAn inherited, autosomal recessive disorder, which affects the exocrine glands and results in multisystem involvement.Most significant factor - The  viscosity of mucus gland secretions = obstruction

45. Cystic Fibrosis • Areas of involvement* Respiratory system* Integumentary system* GI system* Reproductive system

46. Cystic Fibrosis • Major signs and symptoms due to:* Lack of sufficient pancreatic enzymes.* Gradual obstructive lung disease*  sweat gland function.

47. Nursing Diagnoses • Ineffective airway clearance r/t increased mucus production. • Alteration in nutrition -  body requirements r/t malabsorption.

48. Nursing Coventions • Administer and monitor effects of antibiotic, bronchodilator, and nutritional management. • Teach chest PT - MAINSTAY of therapy! • Teach proper postural drainage technique. • Promote exercise, deep breathing and directed coughing. • Teach parents/child s/s of infection and complications i.e. pneumothorax

49. Nursing Coventions • Administer and/or monitor pancreatic enzyme replacement therapy. ** Always administer with meals and snacks - amount given relates to degree of insufficiency and the child’s response to the enzyme therapy. Goal is to prevent FTT and to  number of stools. • Teach parents/child about s/s of Na+ depletion and rectal prolapse

50. The End...